Actually, I was thinking that maybe the audience wants to just see us remove the stent. A lot of times, you know, you're getting a consult because the stent is clogged or say it's pancreas cancer and the patient needs to go on chemotherapy. So at our institution, they will not start chemo. Oncology absolutely requires the patient to have a metal stent. Studies show that, you know, you obviously have a bigger diameter. So the stents don't tend to get clogged and it doesn't interrupt neoadjuvant therapy. So say you're coming back here and then this is actually a big stent. I usually use a mini snare. You can use a grasper also. And so it just depends on, I think, if you have a really easy access to the distal end of the stent. For pigtail stents, I tend to often just use a grasper and come out with the scope. But if you want to go through the scope, you're going to probably you're going to need a snare. So we'll have you open. Probably not all the way. One note for the snares, especially with these duodenoscopes, is snares don't necessarily play very well with the angle these come out. So one thing that I'll mention that I prepped beforehand, I always make sure the snare is at the tip of the catheter. That can sometimes help. But as I open, sometimes you don't get full deployment of the snare. I'm all the way open with my hand on the snare and we see it's not fully opening. That works. Because it's a big snare. Sometimes you can push out the catheter and it will fully open the snare. Ideally, if you can kind of flatten your flap, that's nice too. So it doesn't bend and then make it harder to pull through the scope. And if you grab too much of the stent, it's going to be really hard to pull through. So hopefully this one will come through. Again, I'm holding snug pressure on the snare without too tight. If you are on that flap, sometimes you can damage the stent and as you're pulling out, it will break the stent. Yeah. So just be cautious on how tight of pressure you're putting on the snare as pulling out. All right. Snug, but not too tight. But we'll pretend this is that pain cancer case. So now we took out the plastic stent and now we're going to go with our metal stents. And then again, you have different brands. You have different coatings. You can have an uncovered stent, a partially covered stent where the ends are not coated or a fully covered stent. There's data that shows all tend to have equivalency in terms of patency and safety in general, but fully covered stents tend to migrate more. And then there's also potential for cholecystitis that we always talk about. I think the cholecystitis risk is more a factor of where your stricture is located and how much occlusion you're getting of the cystic duct. But our go-to happens to be partially covered metal stents for the most part. And I usually use a 10 millimeter diameter for the distal duct, but you also have an eight millimeter diameter stent as well. If I'm going up into the liver and the hilum, then I'm going to use an uncovered stent because you just don't want to block off one side of the liver versus the other. And then depending on the size of your intrapadic ducts, that's going to kind of determine the diameter of the stent, but usually you're never going to go above eight millimeters and you might usually use six millimeter metal stents when you're in the hilum. I think another important part, particularly for pancreatic cancer patients who may not be ready for surgery yet are going to get neoadjuvant, you want to be mindful of where you land the proximal end of your metal stent, whether you just want to make sure that you're at least two centimeters below the bifurcation to keep in mind the surgical margin. Excellent point. Because I know in the past there were some chatter about, oh, the surgeons don't like metal stents because then when they go for their Whipple, it causes a problem, but it really doesn't as long as you go two centimeters below the hilum. So they have some duct to anastomose too. And then sometimes there's a question, oh, the surgeons hate uncovered stents. My surgeons, I don't think I have ever really noticed which one I put in. And the oncologists again are just kind of concerned with the metal stent being in. Then let me just see. Oh, you're not all the way. Go a little bit more. It's interesting. So we all have different practices. I would say for distal malignant strictures, I go up front with a fully covered metal stent because I want the long-term patency. I am aware of the migration, but if there's a high level stricture, I would say that migration is pretty rare in that instance. And there was a large retrospective study from Mayo that came out of GIE like two months ago that looked at fully covered versus uncovered. And the uncovereds had more adverse events in time and more subsequent ERCPs because they became clogged more often. And that's usually from tissue ingrowth. It's so funny though, because I feel like the fully covered are very lithogenic and because we use those a lot of times in our liver transplant patients and I leave them in four to six months. And they tend to get so much debris on them. And so I only use fully covered if I don't have a diagnosis or it's a benign biliary stricture and chronic pink or a liver transplant patient. But I know in New York, everybody loves fully covered and then they change it out. But then you change it out regularly in six months or no? No, no. I usually, what I usually, my priority is trying to get the patients to their systemic therapy as soon as possible and to get them out of the hospital. I don't want them to come back even for elective procedures. So that's why I try to use the longest patency stance and really try to avoid any procedures. And obviously it's a multidisciplinary discussion because if they're having close follow-up with your oncology colleagues and they're always checking liver function tests. So if there's any bump of anything, there's obviously a low threshold, but I don't tend to schedule six month changes. Yeah. That's why I, again, almost always do partially covered. I might do uncovered if they have a huge gallbladder that has a lot of debris in it. I might be a little more concerned about cholecystitis, but we actually did a study where we looked at uncovered versus partially covered and we had no difference in any kind of adverse events at all. And we looked at eight millimeter versus 10 millimeter. And again, these were mainly distal strictures and no real difference. So even with that data, because uncovered are cheaper, I still, I do a 10 millimeter partially covered, but we'll show you. And again, there's all different brands from every company. We just happen to have a wall flex stent. And this one, you just kind of pull back on the catheter. The cook stent, you have a gun that helps deploy it. There's a viable stent that has little anti-migration flanges, and that one doesn't foreshorten like these other stents. So you kind of unwrap it by pulling back on the string. And once you're in position, that's kind of it. I like these stents that you can readjust the position, especially when I'm with trainees, if they're starting to deploy the cook in Boston, they have kind of halfway marks where you know, you're, you're halfway deployed and you could still recapture and reposition if needed. And they're pretty low profile in terms of getting through your stricture. So it's rare, you're going to have to dilate unless you're at the high one. But now you see, and this is short wire, so you can see the stent going in. So for, in Chicago, what, how much time do you, a lot for ERCP with general anesthesia? It's a question from the audience. I think we usually book them for 60 minutes. Okay. Our anesthesiologists are pretty quick, I have to say. Well, again, that depends too, but. I would say anything from 60 minutes to 90 minutes. And I think also it depends on how much equipment and how much ERCP that you're going to be doing. So for instance, if you're doing cholangioscopy, lithotripsy, that might take extra time. So I think anywhere from 60 minutes to 90, or even two hours, if you know, you're doing something arduous, but 60 to 90, I think it's right. Alternate anatomy, I'll go 90 minutes or two hours, depending on what that indication is, ampulectomy. But if it's just a stent change, usually it'll be about 60 minutes. So all these stents are 10 French catheters. So again, we have a 4.2 millimeter accessory channel. And the key thing, whenever you put these stents out, the initial passage of the stent out the tip of the scope, it kind of drops everything down. So you have to be ready automatically to come back up, to keep your wire in place. Especially when I'm with trainees, they're kind of shaken when the stent kind of comes out and goes down, and then they start staring at it too long, and then the wire just falls right out. So you just have to know that initial kind of downward trajectory. And then once you're out, then you're good. And then you want to just, again, stay pretty close. And then I usually, I'm looking at fluoroscopy and I'm making sure, again, my relationship to the hilum, but usually once you start the deployment, it will jump a little bit backwards. And the tendency is for the stent to get sucked into the duct. So you're holding backward pressure as the stent is being deployed. And the goal is for you to keep an eye on this yellow marker. So ideally, you want about five diamonds out of the papilla. And I like to just see that yellow kind of peeking out of the corner of my view. And then my goal is just to keep that steady while Steve's going to deploy the stent. And then we first want to get a little bit straighter if we can. It's just difficult with this proximity. I got the wire. Okay, thank you. We're locked. So I don't know if you can flip on his end. Some nurses like to put it up against their chest just to help give some back tension when they're deploying it. But basically we want to straighten this out. You're still a little bit crooked. So the start of the deployment is difficult and that's why- Can you show the end of you also? Some staff like to put it against their chest. It's easy to control that jump she was mentioning at the start. But if you have a little bit of extra controlled strength, you can kind of mitigate it a little bit. The other thing- Oh, hold on one second. If you're not careful and you really crunch this stent with your elevator, you can cause a bend in the stent and the catheter itself. You can sometimes still override that by just bringing it back into the scope to help straighten it. You can see that little mark right there towards the end of the stent. That tends to be sometimes where you may bend it. But if you just pull back into the scope and start the deployment and get it going, then you can push out later. But for the most part, we want to try to stay stable. And a lot of times I see people doing kind of multiple backward movements, but it should just be one tension movement. It shouldn't be kind of jerky multiple steps. So he's going to start deploying. So I've already started kind of holding a little back pressure and you can- Hold on. Hold. Stop. So I could tell we were a little bit out of sync and it was starting to get sucked in a little bit and I wasn't able to control it. So that's fine. We can just readjust our position. Now I see my yellow. Okay. Go ahead and start again. So you see, if you can see my hands too. Oops. Hold on one second. Stop. Can you see my hands as well? So go ahead and keep- Yes, I can see it. Okay. Perfect. Okay. Keep going. Deploying. So he's deploying and I'm just holding. I'm just- We're moving in sync. So when you're doing these metal stances like walking a dog, the dog's always going to want to run away from you. Oh, yeah. And in the beginning, that momentum and the jump is just really transfer of momentum from where you are in the hands and this metal stent that was in this plastic sheet for a long time. It needs a little bit before it gets started, but then once it starts, then you've got the momentum going and it's like a dog on a leash. You got to really pull back. Now, Steve's just showing you the point of no return. So that's kind of the halfway point. And again, that just means that, all right, if I look on Floro and I don't like the positioning of my stent, he can push forward now if you want to. And I'll say, re-constrain. So he'll just push the catheter. Now, say you want to re-constrain. I'm re-constraining. Okay. Yeah. It looks like you're pulling back. No, I want you to push in. So you're going to adjust your stent again. All right. Okay. So now, all right. Perfect. So he re-constrained it a little bit, but now we decide, okay, now we like our position. We're going to go back. Now these stents do foreshorten maybe around like 20 to 30%. So you have to overshoot a little bit in terms of what you want. Point of no return again. Yep. So I like it. I'm going to say, keep going. I can just see my yellow right there. I know I'm out of the scope and then he's going to deploy everything. And then you can see. Now, sometimes if it's a really, really tight stricture, if I just try to pull this catheter back now that the tip of the introducer catheter is separated from the body of it, that tip may get stuck inside of your stent. And especially if it's a fully covered stent, you might pull your stent out. So here's where I'll say, okay, re-constrain because now I'm going to put the tip back together with the body and that's going to make it a little bit smoother withdrawal. So we kind of do that routinely after we deploy the stent, you don't always depend, but it just depends on how tight it is. Yeah. I would say that if you actually look at it when it's separated, the tip of it has a little, it's not smooth. The end has a little like bump. And sometimes, most of the times it's not something that's noticeable, but sometimes it'll get stuck maybe on one of the interstices and you'll panic because you think that the device is actually stuck. But actually, like you said, if you re-introduce the sheath and put it all back together and you get rid of that little notch, you should be able to get out of that position. Yeah. And then I usually, you can just pull your wire now, but sometimes I'll just, you know, I'll keep the wire for a second. I'll suction just, I like to see contrast and bile draining through on fluoro and on endo view. And then I know, okay, my stent looks good. And your goal again, I don't know if we can pan down to this view, but we don't have a stricture here, but ideally you want it to look like a bow tie, right? So your stricture is in the middle and then you have your top open and your bottom trans papillary view have the stent deployed fully where the flanges are definitely outside the papilla. But on fluoro, that's one of the things you want to definitely make sure as you're deploying, do you see the top of the stent expanding fully? If not, then you might be in the stricture and you know, okay, I need to push up a little bit again, keeping in mind, where is the hilum and making sure you do not crowd that area. I think another important thing to remember is that if you are using some of these stents that do foreshorten, you want to make sure that you also accommodate for that when you're measuring out what size or length that you need, because it might be perfect at the time that you place it. But with the foreshortening, you don't want the patient to come back with re-obstruction. Yep. And so, and also, so, you know sometimes with the stent, so the partially covered, the ends are uncovered and safe for whatever reason you wanted to remove it later, it may be difficult because there's been tissue ingrowth on the uncovered part. And similarly with an uncovered stent, if you wanted to get it out later, you could put a fully covered inside to try to cause some necrosis and get the uncovered part off the tissue that's grown in and then pull those. But even on the fully covered, not viable because that is completely coated the whole way, but on the wall flex, like that end flange on a fully covered one that's not completely coated. And we do see tissue hyperplasia on those sometimes, so. A question from the audience is, how worried are you about causing cholecystitis? And I would actually add also pancreatitis when you place covered metal stents. No, I am always thinking about it and I always tell the patients about it. In terms of pancreatitis risk, most of us will do a sphincterotomy before you put in these stents because you wanna take pressure off of the pancreas duct orifice, especially with a fully covered stent. So I will do a sphincterotomy beforehand and you won't do a huge one though because if you go over 10 millimeters then your stent may migrate, but you definitely wanna do that. But I'll do a sphincterotomy even for my plastic stents as well. Also because I don't wanna lose access to the bile duct if I'm gonna have to keep going back in and out on subsequent procedures. But I'm still always worried, but I don't quote them a higher risk. I always say up to 10% chance, less than 1% are gonna be severe cases. And I don't prophylactically put in a PD stent at all if I've never touched the PD. For cholecystitis, again, my concern is raised more, say if I've done an EUS or there's a cross-sectional imaging that says the gallbladder is humongous and it's completely packed with sludge and debris that maybe that patient's already a little bit more at risk for that. And there might be stricture that's partially obstructing the cystic duct takeoff. If I inject the cystic duct and I can see where it takes off and I can try to place my stent below that, then I don't have to worry about which kind of stent I use. If I know I'm gonna cross it, I might switch to an uncovered, but I can't say I do that routinely because partially covered is my routine. And the cholecystitis risk is there regardless, but I don't know if I changed my practice for that. But you use fully covered all the time. So you're obviously not seeing humongous numbers of cholecystitis or pancreatitis. It happens, but I think not in enough cases where you're gonna switch the type of stent you use. Yeah, I mean, I think if you look at all the studies carefully, the ones that had cholecystitis was probably due for stricter involvement of the cystic duct and the takeoff. So it's from malignancy and not necessarily per se the stent. And in that study that I mentioned from Mayo, there was no difference in the rate of cholecystitis or pancreatitis in the uncovered and the covered. So something to think about, obviously. I don't think we know yet, if you get into this, say you get into the cystic duct as well, would you even go so far as to put a trans-papillary gallbladder stent at the same time? Or would you not go there? I have never done that, so. Neither have I. I don't think we know. Yeah, if your stricture is kind of in that area, I think it's gonna be harder to get there. And if it's already obstructed from tumor, probably lower chance that you're gonna cause it. And our own data, uncovered versus partially covered, no difference in cholecystitis rates. But I think these are things you have to be aware of. I always give the patient a heads up. And sometimes we see cholecystitis happen later on, like maybe two months later, the patient comes back with that, so. But we were talking at lunch, there's one study from Carlos Robles that got published earlier this year in GIE where they randomized patients to just getting their metal stent versus metal stent plus prophylactic gallbladder stenting, EUS guided. And they showed less cholecystitis risk in the patients that had the prophylactic EUS guided stent, lumen opposing metal stent place. But there were like five editorials where people said that's going too far to prophylactically treat it, so. But I think, yeah, so I think it's something you're always aware of and you warn the patients about, cause it can happen. But again, most of us have a favorite stent and we kind of go with it. Cause you can find a study that'll support whatever you want for that. You wanna do. Yeah. I mean, I think particularly in cancer patients, it's always less is more, even though maybe your thought process and your purpose wants is for the benefit, but I agree. I think right now we don't have enough data to say that that's something we should be doing routinely. Correct, yeah. Another follow-up question before you guys talk about how you're gonna remove the stent is from the audience, hyaluronstrictures, we were sort of briefly talking about eight millimeters, 10 millimeters. Would you leave the distal end of an uncovered metal stent for a hyaluronstricture within the bile duct and not have a worry if it's not coming out of the ampulla? I try, well, you don't have to, you could go either way because again, the stricture is higher up and if there's nothing in the distal duct, you don't have to come transpapillary. But do I try? Yes, because invariably these patients are living longer and longer and I'm gonna have to go back in. So it's just easier to access those ducts if the stent is coming out of the papilla. That brings up a whole nother question though, because in a lot of centers, including in my own practice, because the clangio patients are living longer and longer, I have moved a little bit more away from putting in metal in the hyalum because they tend to get clogged and then you've kind of blocked off other pathways into the enteropatics and it's just easier to bring them back for that plastic stent change. Because once they start getting occluded, even with metal after that, around that year, year and a half mark, it's still, you end up half the time putting in plastics through them again and then you're kind of back on the same cycle, but now you're limited in where you can go. Okay, we'll close. Yeah, I have the same committal issues. I can't commit to something permanent. Yeah, exactly. Except for distal, distal I'm good with. Well, you still do fully, so you're still not. I'll do uncovers once in a while. I was gonna say, sometimes it comes up when, in these fully cover, there's a lot of tissue ingrowth or say the stent has migrated up into the duct. So you can use a grasper, but sometimes if you grab just one flange and there's a lot of tissue hyperplasia or it's embedded a little bit into the mucosa around the papilla, you can break that flange or just stretch it out really far and you won't be able to pull the stent back. So oftentimes if you have enough stent to grab and it's not attached to the mucosa, it's nice to use a snare. And then also if it's migrated into the duct and you need to get it out, I'll use fluoroscopy to try to guide my mini forceps and I'll kind of bend the tip and use fluoroscopy to grab, hopefully more than one flange so that I could bring that out as well. But sometimes you can run into trouble with that. Now, you can pull these stents through the scope, but it's really hard. So usually for metal, I will just come out with the stent. But, all right, any other questions? Because then we might take a break and switch over. Yes, we have a couple of other questions. What do you like to do placing bilateral hiler metal stents? What do you like to do? So you have a couple options there and it can be tricky. I think the key thing always is, you definitely wanna have both wires up first. If you try to deploy one stent and then go the other, forget about it. So you wanna get both wires up first and then you wanna put up both catheters. I usually try to do them together, if I can. That takes a little bit more coordination in terms of our assistants. And if you're gonna do simultaneous, you need two assistants who can coordinate deploying those. And then the wall flex ones, you can re-constrain, sorry, the longer Boston stents that are not re-constrainable and then also Zilver stents by Cook, they're not re-constrainable either. So you have to really coordinate, because once they open, that's kind of it for the position. But I like to do simultaneous if I can. But if you don't have extra hands that day, I put up both catheters and then we'll deploy one stent and then the other. So I think that's a good option as well. Do you prefer side-by-side or do you like to go Y? Oh, side, side-by-side. But do we have Y in the US now though? That's a question. I know in Asia, they like those. Right, it's really, really boring through one of the interstitials and going through. I will never do that. Yeah, I think it's a lot of extra work. I just do side-by-side. But there are Y stents though that are configured that way as well. But again, and usually we're doing uncovered stents and either six or eight millimeters. It's rare that you have, I mean, if you had humongous intrapadics, you could do that and put larger caliber stents, but usually it's gonna be eight or six into the intrapadics. And again, you wanna look for that same configuration where you see the top of the stent opening and then pull down. Now, sometimes if I don't come out the papilla, I may put another stent inside and kind of overlap them just so I do come trans-papillary. But do you always try to go trans-papillary as well? I always try to go trans-papillary, just like you said, because I know they're gonna have to come back and I want my next session ERCPs to be smooth. I would say that for Hyler work, it definitely takes higher level staff training. I would say that if you don't have experienced staff, I would do one at a time, because that's something that your staff would be familiar with and that you would be comfortable with. The simultaneously deployed metal stents by the two companies mentioned are great because they can be both bit into your catheter channel. When you have your wires up, they're five inch. You have to put some kind of either silicone PAM or something. Otherwise, it's never gonna work. Yeah. You've got friction for sure. And both of them are long wires. So you really have to be comfortable with the exchange and how steady you are with wire access, because obviously the last thing you wanna do after doing all this beautiful access work is lose one of your wires. And then of course, the main thing is, as we know, whichever way you decide to do, it doesn't matter, but we do know that you have to drain more than 50% of the liver and that's what your goal should be. And then these are long links. We're talking 10 centimeters, 12 centimeters, which are nice, because then hopefully you can get out the papilla without having to overlap, but you never know depending on how far out you have to get into the liver. But again, I've kind of moved a little bit more towards plastic stenting, just given the improvements in kind of chemotherapy and patients living longer. Last question for you guys, which is kind of a doozy. One of the participants asked, say you have somebody who presented with the malignant obstruction, but it was really predominantly duodenal obstruction. So you place a duodenal stent, but at the time they didn't have biliary obstruction, so you didn't justify to do an ERCP, the LFTs were normal. But now of course, they've progressed with their disease and they've come jaundiced. What do you do? Do you try to do an ERCP and place a metal stent through that duodenal stent, or should you just go straight to IR? Okay, that is a doozy and there are five different ways you could do it depending on your level of expertise and your center's kind of backup services, IR services. So I think the easiest option and that what most centers probably have the easiest way to get to is IR, to put in a PERC drain, because even IR could potentially internalize that later as well if they can get an internal external stent. When you're placing your duodenal stent, well, that goes back to another question. Should you do duodenal stent versus an EUS-GJ? So you potentially could go through and to grade through the GJ stent to get to the papilla. But if you have a duodenal stent and if possible, you could try to make sure it's short enough that you're proximal to the papilla. And then after it's maximally opened in a week or two and pretty secure in its position, you could try to pass your ERCP scope through that to get to the papilla. But again, you have to wait for that stricture to open up and that doesn't happen overnight. You can try to pass your scope through. And if the stent is across the papilla, you can try to manipulate through the interstices of that metal stent. I think that's super hard to do. So I won't say that that would be something I would necessarily do depending on where your stent is, and how much is in the duodenal bulb you could, and how dilated the bile duct is. You could try EUS guided biliary drainage techniques, either coledoco duodenostomy stent, directly say from the bulb into the bile duct. You could try EUS guided hepatico-gastrostomy stenting through the stomach, or that's a little bit higher risk, a little bit more technically challenging to do, but something that a lot of us who do therapeutic EUS may be a little bit more comfortable with. There is a growing body of data that says you could drain the gallbladder with a EUS guided lumen opposing metal stent as a secondary way to drain the bile duct. And that's essentially, it's almost like draining a pseudocyst if you have a nice distended gallbladder that's up against the duodenal wall. So you have a lot of options, but it depends on what you're comfortable with. And I do not think that going to IR is the worst thing in the world, but I have colleagues that do think that. So they're gonna definitely handle it endoscopically. But what do you guys do? It depends, right? It depends. What time of day, what weekend? Yeah, it depends. But I would say that the least favorable option is trying to do an ERCP through a duodenal metal stent. It's just so frustrating because there's levels. They have nice videos online where the papilla is right between the interstices and it's perfect, but it's really hard. And if it's a really tight malignant stricture, that stent may not maximally expand to that 23 millimeter diameter, but I think it's really hard to go through. So unless you know you put in a really short one that's maybe the shortest is six centimeters and you're in front of the papilla, or say it was just distal to the papilla and you can still get to it, that's when I would try. But otherwise, it's nice that we do have some other EUS guided options nowadays, but it's hard because they don't come up as often. So you may not be as proficient, or you or your staff in doing those techniques, so. Agree. But whenever I put a duodenal stent, I always discuss with the patient the status of the bile duct. And that's what I always teach my trainees as well. And say, if the bile duct is dilated and the ALKFOS is up, but they're not jaundiced yet, in most cases, I'm still gonna try if I can get my scope down to the papilla to try to put in a metal biliary stent and deal with that bile duct right then. But if all the LFTs are normal, bile duct's not dilated, I'll just tell the patient, listen, after I put this duodenal stent in, there's a chance that you may need additional therapy if you become jaundiced. Agree. All right. Okay, we're gonna take a quick break and try to change out models. We'll be right back.

metal stents

bile duct

duodenum

cholecystitis

pancreatitis

gallbladder stents

jaundice